Triage is an indispensable tool in major incidents. Patients can be quickly prioritised into the urgency of need. Whilst extensive research has been conducted into adult major incident triage tools, there had been limited research in the paediatric population. A challenge in the paediatric population is designing a fit-for-purpose paediatric major incident tool that can take account of age-related paediatric physiological thresholds then determine the need for intervention.
Currently, there are two paediatric major incident triage tools in use in the UK: the Paediatric Triage Tape (a prehospital tool used in the under 12s) and JumpSTART, (an in-hospital tool used in patients under 9 years of age). Recently, the Sheffield Paediatric Triage Tool (SPTT), a paediatric adaption of the MPTT-24 triage tool, was developed as an alternative tool. It has been tested in a simulated paediatric major event where it successfully triaged all study patients, potentially giving a possible alternative to existing tools (cited by the authors as personal communication with C. O’Connell in 2020).
In this paper Vassallo et al. attempt to compare the SPTT and MPTT-24 tools to seven other paediatric tools in order to assess their ability to correctly identify patients in need of life-saving Intervention.
Vassallo J, Chernbumroong S, Malik N, Xu Y, Keene D, Gkoutos GV, Lyttle MD, Smith JE, in collaboration with PERUKI (Paediatric Emergency Research in the UK and Ireland). Comparative Analysis of Major Incident Triage Tools in Children – a UK population-based analysis. https://doi.org/10.1101/2021.06.29.21259604
Aim of the study
This was a retrospective comparative analysis of nine adult and paediatric triage tools aimed at establishing each tool’s ability to correctly identify the need for life-saving interventions in the under 16-year-old population who have sustained moderate to severe trauma.
What did they study?
The study used retrospective data from the Trauma Audit and Research Network (TARN) database over a 10-year period. All patients under 16 years old were included if they had either a hospital admission for more than three nights, a transfer to a specialist centre or admission to a critical care centre.
What were the outcomes measured?
The primary outcome was to assess the ability of each triage tool to correctly determine which patients are of a priority one status (needing at least one lifesaving intervention).
The secondary outcome was to assess the ability of each triage tool to predict major trauma (ISS* >15) and mortality.
*What is the ISS? The ISS is the Injury Severity Score, a score of trauma by anatomical body part(s). It gives a number – or score – to denote the severity of a patient’s injuries. The higher the score, the more severe the injuries. The ISS is an internationally recognised number that’s particularly helpful for research and audit purposes. TARN, the Trauma Audit and Research Network, give a worked example of how ISS is calculated here.
How was the study performed?
The performance characteristics of each triage tool were evaluated by assessing the sensitivity, specificity, rates of under-triage (1-sensitivity) and over-triage (1-positive predictive value). The primary analysis of the data was conducted on patients with complete pre-hospital physiological data, whilst secondary analysis was performed using first recorded data.
What were the results?
15,133 patients met TARN inclusion criteria. 8,255 patients had complete first recorded data available. Complete pre-hospital data was available in 4,962 patients.
For the primary outcome (the need for life-saving intervention) SPTT had the greatest sensitivity of all the paediatric and adult triage tools at 92.2% (95% CI 90.5-93.7) followed by the adult MPTT-24 triage tool at 80.8% (95%CI 78.4-85.0). These are both far superior to the Paediatric Triage Tape (PTT) which had shown a sensitivity of 34.1% and JumpSTARTat 45.0%. SPTT and MPTT-24 are superior in identifying patients needing life-saving interventions.
For the first secondary outcome (detecting paediatric major trauma, i.e. an ISS >15), SPTT again had the highest sensitivity at 91.8% (95%CI 90.5-90.3%) followed by MPTT-24 at 75.6% (95% CI 73.5-77.7%). Both PTT and JumpSTART were much less sensitive at predicting major trauma (PTT 28.8%, and JumpSTART 36.0%).
When it came to the other secondary outcome, predicting mortality, all tools had similar sensitivities between 84-97%, except PTT with the lowest sensitivity at just 71%.
What about over/under triage?
For the primary outcome, both SPTT and MPTT-24 had a low rate of under-triage (SPTT the lowest at 7.8% and MPTT-24 at. 19.2%) compared to PTT and JumpSTART, both of which had high under-triage rates (PTT 65.9%, JumpSTART 55.1%). As with many triage tools, a low under-triage rate often means a high over-triage rate. Both SPTT and MPTT-24 were prone to over-triage (SPTT 75%, MPTT 70.2%) compared to PTT and JumpSTART (PTT 56.7%, JumpSTART 35.7%).
For the secondary outcome detecting patients with an ISS >15, both SPTT and MPTT-24 again had lower rates of undertriage (SPTT 8.2%, MPTT-24 24.4%) compared to PTT and JumpSTART (PTT-71.2%, JumpSTART-64.0%). However, again, both SPTT and MPTT-24 were prone to over triage (SPTT 66.4%, MPTT-24 62.3%) compared to PTT and JumpSTART (PTT 50.7%, MPTT-24 62.3%). Similar findings were seen in the other secondary outcome, predicting mortality. SPTT, MPTT and JumpSTART had similar rates of undertriage (SPTT 13.2%, MPTT-24 17.0%, JumpSTART 11.3%) whilst PTT had a significantly higher rate of undertriage (28.3%). All triage tools had similar rates of over triage (SPTT 92.2%, MPTT-24 98.6%, PTT 96.0, JumpSTART 94.4).
Were there any limitations to the study?
Assessing a developmental triage tool in the real world is challenging. This study design was therefore retrospective observational. The biggest limitation, therefore, was navigating the problem of missing data. Of the patients eligible to be included in the study, a significant proportion (67.2%) had incomplete pre-hospital data leading to a high risk of information bias. Whilst this was mitigated somewhat using multiple imputation, the paucity of pre-hospital data cannot be ignored.
The headline message from the authors is that the new paediatric SPTT tool and adult MPTT-24 tool are the most accurate of the tools studied at predicting the need for life-saving interventions, as well as major injury and mortality in children. Whilst this is a retrospective study, Vassallo et al manage to demonstrate stark differences between different triage tools, making a very strong argument for the adoption of the SPTT.
As described by the authors, a triage tool needs to be rapid, reliable, and reproducible irrespective of who performs it. Is SPTT rapid? The completion time isn’t included in Vassallo’s article, so we cannot comment. Is it reliable? This is seen as an assessment of its performance, i.e. the ability to correctly identify those in need of life-saving interventions, whilst minimising under-triage. The authors have shown that not only is SPTT reliable, but it is also more reliable than the traditional PTT and JumpSTART tools. And is SPTT reproducible? Reproducibility wasn’t described in Vassallo’s article so again we cannot comment.
Whilst the SPTT holds the highest specificity, it is also the most complicated tool to use. It incorporates five different age brackets, each with different physiological variables. This complexity may make it impractical to use, particularly in the prehospital setting. Vassallo’s team suggest using a single tool for both adults and children involved in a major incident to reduce complexity and therefore reduce cognitive load and improve bandwidth. This would mean compromising sensitivity and over-triage. PERUKI are currently conducting a DELPHI consensus survey into the components of an optimal paediatric major incident triage tool. Perhaps this will shine a light on characteristics of the idea major incident triage tool for children?